TN 3 (02-97)

NL 00802.015 Completion of the Manual SSA-L8025-U2, Notice of Award

A. INTRODUCTION

The SSA-L8025-U2 is a manual form with preprinted appeal rights. Select captions and paragraphs from those shown below to produce a complete notice. The SSA-L8025 is also on the DOCS for completing the notice on a personal computer.

B. PROCEDURE

1. Completion of Payment Information

Under the preprinted opening paragraph, is caption 1901, “How Much We'll Pay,” followed by three column headings, “Beginning,” “Through” and “Amount Due.” (paragraph 1011, NL 00804.115).

  1. a. 

    Under the “Beginning” column enter the month, day and year of application or the protected filing date if earlier than the date of application.

  2. b. 

    Under the “Through” column enter the last month, day and year that the payment amount continues unchanged. If the same payment amount continues through the current computation month, type “Continuing” instead of a month, day and year.

  3. c. 

    Under the “Amount Due” column enter the actual monthly payment amount. When this amount includes a federally administered optional State supplementary payment, include the following statement directly below the amount due:

    “(This includes $       from the State of (State Name)/ District of Columbia.)”

  4. d. 

    Repeat payment information as necessary. Show $00.00 if no payment is due.

2. Chart for Completing the SSA-L8025-U2

The following chart provides a list of additional captions and paragraphs to use when you prepare a manual SSA-L8025-U2.

  1. a. 

    OUR DECISION ABOUT HOW WE'LL PAY YOU (Caption 1919) (Use this caption and the following paragraphs only if there is representative payee involvement.)

NL Reference Paragraph Use
00804.185 1291
1609
Notices to claimant and representative payee — Choose the appropriate paragraph — SSI payments will go to a representative payee.
1290
1608
Notice to representative payee only — Payee's responsibilities. Choose the appropriate paragraph. (See NOTE: under B.5 that tells how to avoid preparing a separate notice to the representative payee.)
  1. b. 

    INFORMATION ABOUT YOUR PAYMENTS (Caption 1905) (Mandatory)

NL Reference Paragraph
A00804.166 1623 Recipient is in an institution, and we are sending the eligibility notice in the second or third month of institutionalization but prior to G/K cutoff for reducing/stopping payment in the fourth month.
1624 Recipient is in an institution, and we are sending the eligibility notice after G/K cutoff for reducing/stopping payment in the fourth month.
00804.115 1479 Retroactive in addition to or without ongoing SSI payments due.
1486 Regular payment due (no retroactive money due).
1480
1484
Claimant has already received payment for a past period — Choose the appropriate paragraph.
1012 Lead-in for payment of first check.
1025 Claimant has received an advance payment, one-time payment (OTP),and/ or presumptive disability/blindness (PD/PB) payment. Retroactive SSI payment is offset by advance payment, OTP and/or PD/PB payment.
00804.125 1046 Interim Assistance Reimbursement (IAR) involved (Mandatory if IAR involved).
IARM01
1069
Six-month exclusion of retroactive SSI payment which is part of an IAR refund check.
00804.180 1270 Agreement to dispose of excess resources—reminder.
00804.120 1040
1041
Claimant received advance payments — Choose the appropriate paragraph.
1048
1483
00804.200 1370 Payment due for a retroactive period netted against prior payments.
00804.160 1180
MARM55
Adjustment of payments due between members of a couple.
1186
MARM56
Spouse's application pending.
00804.130 1080 Filing for other benefits—reminder.
00804.210 2526 Claimant may be due retroactive payments.
1440
1436
Overpayment on a prior record — Choose the appropriate paragraph(s).
1016
1018
1017 Overpayment on a prior record — Follows paragraph 1436 or 1018, above.
00804.205 1418
1431
Making presumptive disability payments pending final determination.
1188 Award for one member of a couple — presumptive disability payments to other member pending disability determination.
1432 Presumptive disability payments stopped after 6 months — final determination pending.
00804.174 DCOM03 Children of Armed Forces personnel who live outside the United States.
  1. c. 

    YOUR PAYMENT IS BASED ON THESE FACTS (Caption 1907) (Mandatory)

NL Reference Paragraph Use
00804.235 1014 Tells claimant the first day of eligibility for proration Mandatory.
00804.145 1130 Tells claimant category(ies) of eligibility — Mandatory.
1131 Spouse is eligible for SSI — Tells the spouse's category(ies) of SSI eligibility.
00804.190 1315 Tells where the claimant resides — Mandatory.
2970 Says that State rules determine the amount of payment.
1168 Describes the State living arrangement.
00804.160 1161
1183
Spouse involvement — Choose the appropriate paragraph(s).
1185
MARM54
MARM57
00804.155 1165 Describes living arrangement (LA) “C” or “D”.
00804.150 1145 Describes student status of a child.
00804.170 1001
1002
If sponsor-to-alien deeming applies always use both paragraphs.
00804.174 DCOM04 Child is living overseas with a parent who is in the Armed Forces.
The following paragraphs address income related issues:
00804.175 1240 Claimant has no income/deemed income.
1231 Income lead-in paragraph.
1616 Income lead-in for E01.
2233 Lead-in for monthly countable income.
1280
1281
1282
Windfall offset applies — Choose the appropriate paragraph.
If the claimant has income, consider:
1601 Income disregards reduce chargeable income to zero.
1232 Describes type, period and amount of countable income.
1253 Claimant received a one-time payment of unearned income.
1260 Claimant receives in kind support and maintenance.
1258 Value of the one-third reduction (VTR) applies.
1603 Claimant has a net loss from self-employment.
1257 Special income disregards apply for earned and/or unearned income.
1602 Student earned income exclusion applies.
1252 Overpayment withheld from income other than SSI. (Do not use in the Ninth Circuit.)
If the claimant is subject to deeming, consider:
1249 Spouse or parent(s) receives public assistance — no deemed income.
1601 Deemed income does not affect amount of SSI payment.
1257 Special income disregards apply for earned and/or unearned income.
1604 Spouse or parent(s) has net loss from self-employment.
1248 Income of spouse or parent(s) deemed to claimant.
1234 Deemor's income deemed to claimant.
1254 Spouse or parent(s) received a one-time payment of unearned income.
If the claimant has periods of ineligibility, consider:
00804.175 1239 N01 — Claimant has excess income.
00804.165 1200 N02 — Claimant resides in a public institution.
00804.170 1216 N03 — Not residing in U.S.
00804.140 1118 N14 — Claimant has not attained age 65.
If the claimant has a period of ineligibility for disability-related reasons, consider:
00804.200 SGAM50
1383
Claimant performed substantial gainful activity (SGA) during a closed period.
1373 Date of onset is later than filing date.
00804.174 DCOM04 Children of Armed Forces personnel who live outside the United States.
  1. d. 

    INFORMATION ABOUT YOUR BACK PAYMENTS (Caption 1908) (Use when paragraph 1497 or paragraph DCOM05 below applies.)

NL Reference Paragraph Use
00804.180 1497 Claimant will receive a retroactive SSI check(s) and there is no IAR involvement or will receive a retroactive title II check(s)—6-month exclusion from resources applies.
00804.174 DCOM05 Children of Armed Forces personnel who live outside the United States.
  1. e. 

    ABOUT YOUR OVERPAYMENT (Caption 1909) (Use when the claimant had an overpayment from a prior application or has an overpayment due to advance payments.)

NL Reference Paragraph Use
00804.210 1441 Claimant has an overpayment from a prior application.
00804.120 1044
1049
Choose the appropriate overpayment paragraph. These paragraphs give the amount of SSI paid and the amount that should have been paid.
1043 Overpayment caused by incorrect advance payment amount — no ongoing payment due.
  1. f. 

    IF YOU THINK YOU SHOULDN'T HAVE TO PAY US BACK (Caption 1911) (Mandatory when the preceding caption (1909) is used.)

NL Reference Paragraph Use
00804.210 1434 Provides claimant with waiver information — Mandatory with caption 1911.
  1. g. 

    INFORMATION ABOUT MEDICAID (AND OTHER BENEFITS)(Caption 1915) (Mandatory) (Use “AND OTHER BENEFITS” in the caption only if paragraph 1311 below is used.)

NL Reference Paragraph Use
00804.110 1150
1151
1155
1170
Choose the appropriate Medicaid referral paragraph for the claimant's State of residence. (Use 1155 only when a claimant is currently ineligible for SSI and resides in a State where an SSI application is also a Medicaid application.)
1146 Claimant did not provide third-party liability (TPL) information.
1149 Claimant did not provide assignment of rights (AOR) information.
1156 We are developing for claimant's eligibility under 1619(b).
1152 Recipient resides in or moves to a State in which SSA makes Medicaid decisions. Eligibility for payment is suspended or terminated.
1189 Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State for which SSA makes Medicaid determinations.
1196 Potential 1619(b) when an aged individual becomes ineligible due to excess income, has countable earned income and resides in a State that makes its own Medicaid determinations.
1158 Reporting responsibilities for 1619(b) eligibles in States with Federal Medicaid determinations.
1159 Reporting responsibilities for 1619(b) eligibles in States with State Medicaid determinations.
1142 Notifies title II widow(er)s age 50-65 who receive SSI of the possibility of special Medicaid eligibility per SI 01715.015B.5.
1191
1192
1193
Reporting information—Use all three paragraphs under paragraph 1158 or 1159 above.
1166
1167
1179
Eligible for closed period. Choose appropriate paragraph.
1147 Used only for individuals in State that makes its own Medicaid determinations. Case is referred to State for determination because a Medicaid Qualifying Trust may be involved. This paragraph tells the recipient to contact State Medicaid agency for information.
00804.174 DCOM06 Child living overseas with parent(s) in Armed Forces.
00804.190 1311 Mandatory when the State administers its own supplementation program.
  1. h. 

    WHERE YOU CAN APPLY FOR MEDICAID (Use only when you use paragraph 1142 above under the preceding caption.)

NL Reference Paragraph Use
00804.110 1144 (Mandatory paragraph for this caption.) Tells title II widow(er) beneficiaries age 50-65 where to apply for Medicaid (SI 01715.015B.5.).
  1. i.  

    WE WILL REVIEW YOUR CASE (Caption 1927) (Use only when you have used paragraph 1158 or 1159 above.)

NL Reference Paragraph Use
00804.110 1190 (Mandatory paragraph for this caption.) Information for 1619(b) eligibles about continuing disability reviews.
  1. j. 

    THINGS TO REMEMBER (Caption 1926) (Mandatory)

NL Reference Paragraph Use
00804.240 1482
1615
(Mandatory paragraph.) Notifies eligible claimants about reporting responsibilities. Choose the appropriate paragraph.
1620 Advises claimant to report changes even though no SSI payments due now.
1481 Advises the claimant to refile if he/she believes he/she can qualify for SSI.
1487 Title II decision will be in a separate notice.
1000 Refers to an additional notice in either English or Spanish.
00804.245 1598 No title II (or additional title II) benefits payable.
00804.220 2834 Value of the one-third reduction (VTR) may not apply if claimant begins to pay pro-rata share of expenses.
00804.130 1606 Claimant must file for other benefits.
00804.174 DCOM01 Blind or disabled children living overseas should contact SSA when they return to the United States.
00804.210 1438 Claimant may be overpaid.
00804.190 1313 Claimant waived SSA-administered optional State supplement payment.
00804.160 1181 Spouse also filed for SSI and will receive a separate notice.
00804.150 1456 Child is age 18 and does not attend school regularly or over 18 but under 21 and stops attending school regularly.
00804.200 1414
1415
1424
1425
Choose the appropriate paragraph to tell a disabled/blind claimant about continuing disability reviews.
00804.205 1419 Reminder to cooperate. Presumptive disability payments made.
00804.185 2489 Representative payee will receive a copy of notice.
00804.207 1650 Introduces paragraph 1651, the enclosure, “SSI RULES THAT HELP SSI RECIPIENTS WORK.”
  1. k. 

    DO YOU DISAGREE WITH THE DECISION?/HOW TO APPEAL/IF YOU WANT HELP WITH YOUR APPEAL (Paragraph 1726) (Mandatory)

    Appeal rights are preprinted as part of the manual SSA-L8025-U2 and also appear on the FONS version of the notice.

  2. l. 

    IF YOU HAVE ANY QUESTIONS (Caption (Unnumbered)) (Mandatory)

NL Reference Paragraph Use
00804.240 MISM53 Closing paragraphs (Mandatory) —Choose the appropriate paragraph.
1704 Refers to enclosure(s) — Mandatory
00804.174 DCM02 Use on ALL notices to children living overseas.

3. Signature

Close the notice as follows:

  •  

    Name of Manager

    Title

4. Enclosures

  1. a. 

    Always enclose the pamphlet, “When You Get SSI... What You Need To Know.” (Pub 05-11011)

  2. b. 

    If the claimant is age 14 or older and blind or disabled, enclose “SSI Rules That Help You Work” (NL 00804.207, paragraph 1651).

  3. c. 

    Always enclose the pamphlet, “A Guide for Representative Payees” (Pub 05-10076) when the notice is sent to the representative payee.

  4. d. 

    Two lines under “Title,” at the left margin, type “Enclosure(s)” and list the enclosures, starting a new line for each one. (If you need a copy of the notice for the representative payee, see the note under 5 below before typing this.)

5. Notice Copies

Two lines under the list of enclosures, at the left margin, type “cc:” if you are sending a copy of the notice to a representative payee, appointed representative and/or legal guardian or other person who is required to get a copy. List the name(s) of the individual(s) to whom you are sending a copy and under each name list the city and State of the individual's address.

NOTE: When you must send both the representative payee and the claimant a copy of the award notice, add the caption, “Our Decision About How We'll Pay (Claimant's Name)” to the representative payee's copy below the signature line at the left hand margin. Insert paragraph 1290 or 1608 here instead of in the body of the notice. (If you do this, you will not have to prepare two separate notices.)

C. REFERENCE

Preparation of a Manual Notice, NL 00801.010 ff.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900802015
NL 00802.015 - Completion of the Manual SSA-L8025-U2, Notice of Award - 02/27/2003
Batch run: 02/27/2003
Rev:02/27/2003